Any billing specialists here?

[Kevinf]

We had a user or two awhile back that stated they were very familiar with the billing/insurance/CMS side of EMS, I was wondering if anyone with that pedigree was still hanging around here? Anyone that actually submits charts to insurance for reimbursement?

 

[akflightmedic]

Post your question.

 

[Kevinf]

Our billing department is getting a little iffy about chief complaints, paraphrased "because ICD-10". Our company policy is that the CC on our ePCR must match our paper chart PCR exactly. Both are required by our billing department, and yes we end up charting in duplicate and triplicate. But that's an argument for another time, however. The issue is that our billing department is requesting "a more complete chief complaint" and my response is that the CC is explained in detail in the History of Present Illness, please refer to that for more information due to lack of space on paper chart for extensive CC's. The response back was that "insurance/medicare/voodoo shaman" doesn't read the HPI.

This makes little to no sense to me. Having not personally done billing submissions I can't say that isn't true, but it sure sounds odd to my ears. My understanding is our billing staff's job is to read our charts, generate the appropriate ICD-10 billing codes internally and submit them and any supporting documentation (PMNC, etc) to whomever for reimbursement. I'm not sure why the payer would be "reading" the chart outside of an audit or spot checks. So I'm looking for an outside party familiar with this process to weigh in with any guiding light.

Here is an example of an inadequate CC:

Chief Complaint (Category: Transfer / Interfacility / Palliative Care)
Blood transfusion

History of Present Illness
This patient has a history of ovarian and thyroid masses diagnosed as malignant tumors by her oncologist. She is receiving chemotherapy in order to treat her cancer, resulting in anemia due to cell damage from chemotherapy per infusion clinic nursing staff. This anemia is being treated via blood transfusions, staff stated she is to receive 1 unit.

 

[akflightmedic]

The CC is not blood transfusion. That is a treatment for the CC...

So your CC needs to be what the issue is which seems to be CA (ovarian and thyroid) or possibly Transport for Chemo/blood transfusions secondary to CA. I would however prefer the first example.

So your employer is correct. And do remember, this is how your employer generates revenue to pay you and to keep all your colleagues employed, so try to cooperate on these billing quirks. They are not much fun for the in house staff either.

 

[akflightmedic]

Or the CC should be anemia secondary to treatment for CA.

Think of root cause analysis when putting down your CC. This is an important concept in just about anything we do in life although most won't overthink it and apply it outside of the safety (HSE) world.

You putting the right CC also streamlines the entire process and helps increase revenue. It is easy to say or think "that is the billing department's job", but in reality it is all of you guy's jobs. If you put the right CC to start with then all they have to do is submit with the proper supporting documentation. The less time the billing coordinator spends deciphering your report, the faster they move onto the next one and profit is generated. The neater you write, the better documentation you have, the less mistakes you have, the better for everyone.

Truly, the Medic or EMT holds a lot of control over how and when the company can get paid...hence the hard-assery it sounds like you are experiencing.

I do not work for Acadian, however they are one of the leaders in figuring out the billing world. I did some emergency contract work for them back in 2005/2006 during several bad storms (Katrina and Rita) and I was very impressed with their billing system. Every Medic/EMT would call in their reports. They have paramedics who have been trained in billing and those folks run the call in center. You literally dictate your runs to them and they enter all the data, they ensure all the boxes are ticked and proper terminology description is used. At first I was very freaked out by this, but it suddenly became very nice. If you do not state something relevant, they have prompt questions where you say "oh yeh, this and that" and then of course they have their experience to ask you if you saw this or did that as well. At the end of the shift, all of your reports are then sent back to you for final review. If you agree, you sign them. If you do not, then you make the changes or corrections then sign. Sweet right?

A lot of this from your employer is legitimate. Any medical business is tough, especially with billing and then capturing revenue. As an employer, you need staff who are committed to the company, who do their best every day. I have been on both sides of the coin and no matter how easy it looks or how rich the bosses or owners look, it is not always what it seems.

Here is a typical scenario and note the timelines...

Day 1: You run the call and submit paperwork.
Day 2-3: Billing reviews and submits (this is actually faster than most billing submissions which typically take a week or more due to mistakes, delays and back logs)
Day 4-5: Insurance company receives it.

The insurance company now has up to 90 days to make payment, deny, request more information!!!!

Day 89: Insurance company rejects payment, wants more info but is vague in what exactly.

This is now kicked back to your company 3-5 days later via mail and the above process starts all over. Only this time, your coordinators have to chase YOU for corrections or clarifications (possibly) and once received....

So that same claim is now resubmitted and guess what???
The insurance company now has 90 days to review and make payment, deny or reject. And YES...some companies do this over and over as they are playing the "float the cash" game.

Then around day 180, the insurance company will say We do NOT approve your bill of $100, however here is payment of $70...take it or leave it.

So as the business you TAKE it because you need cash and you have now been floating THEIR bill for 6 MONTHS!!!!

In addition to the partial payment, you have already used up more than half of that when you factor in all your employee's hands/time who have touched it. Essentially you have spent more than what the payment is trying to collect the payment. It is ridiculous.

Multiple this process by the 10000s and then see why so many services crumble. It takes a large bankroll to float operations such as ambulance service. Sure, eventually payments start to catch up and lessen the pain of this process but it does not mean the process has gotten any better. You could suddenly hit dry spells where everything is rejected and cash reserves start to dwindle (payroll, overhead, normal operating costs) and then of course employee attrition rears its ugly head.

Insurance billing is a nasty. nasty world and so much of it could be improved by the very first person who writes the chart.

 

[Kevinf]

Thanks for your input! I'm going to setup a small meeting because there are a few conflicting requirements making an "appropriate" CC difficult at times, including not using acronyms in CCs, CCs must be an exact match between PCR and ePCR, but with very limited space on the paper chart (I've tried "see notes section for CC" to fit in a longer one but was told that was not acceptable), and our FTOs are training to generate CCs as I have above, i.e. CC is what was the appt for, not what was the underlying condition, so a transport to Chemo would be "Chemotherapy", not "XYZ Cancer Treatment" per our field training. "Transport for Chemo/blood transfusions secondary to CA" wouldn't remotely fit in the space we are provided (also "bad" because it has an acronym and a truncated word), and this wouldn't be the first time I've asked for a revision to our paper charts to accommodate longer CC's.

It can be quite frustrating for everyone involved. It seems like billing requirements have evolved, but our process has not, which is a management issue that needs addressed.

 

[Kevinf]

Edit to above: meant abbreviations, not acronyms, just in case there is any confusion

 

[heavenjoans7]

I didnt know anyone else here who was a biller. Nice I have a degree in it and a little experience and didnt like it so I chose to become an emt. I don't know much about it now since I have forgotten most of it now. lol.

 

[Summit]

ICD-10 wants specificity for a diagnosis.

Bad:
Blood xfusion - codes to NOTHING

OK:
Blood xfusion for Anemia - codes to "anemia unspecified"

Better:
Blood xfusion for aplastic anemia - codes to "aplastic anemia unspecified"

Best:
Blood Xfusion for aplastic anemia secondary to antineoplastic chemotherapy

Expecting a Paramedic to write to that level of specificity is dubious. Expecting an EMT to do that is beyond silly. It is extremely hard enough to get prescribers to be that specific as reliably as the medical coders would like.

But, I don't really understand why EMS billing needs that level of specificity. I don't know EMS billing... I thought it was based on what level of service and what interventions were provided?

 

[akflightmedic]

I just gave the business side of it...and I do not think my explanation or expectation is unreasonable.

But then again, there are talkers and there are doers. Some are both, like me.